Downloaded from http://ard.bmj.com/ on October 8, 2017 - Published by group.bmj.
com
Clinical and epidemiological research
Handling editor Tore K Kvien
▸ Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
annrheumdis-2014-205431).
1
Division of Rheumatology,
Perelman School of Medicine,
University of Pennsylvania,
Philadelphia, Pennsylvania,
USA
2
Department of Medicine,
University of Otago,
Wellington, New Zealand
3
Department of Rheumatology,
Radboud University Medical
Center, Nijmegen, The
Netherlands
4
Sections of Epidemiology and
Rheumatology, Boston
University School of Medicine,
Boston, Massachusetts, USA
5
Department of Medicine,
University of Auckland,
Auckland, New Zealand
Correspondence to
Dr Alexis Ogdie, Division of
Rheumatology, Perelman
School of Medicine, University
of Pennsylvania, Philadelphia,
PA 19104, USA;
alexis.ogdie@uphs.upenn.edu
Received 17 February 2014
Revised 13 May 2014
Accepted 25 May 2014
Published Online First
10 June 2014
To cite: Ogdie A,
Taylor WJ, Weatherall M,
et al. Ann Rheum Dis
2015;74:1868–1874.
1868
EXTENDED REPORT
Imaging modalities for the classification of gout:
systematic literature review and meta-analysis
Alexis Ogdie,1 William J Taylor,2 Mark Weatherall,2 Jaap Fransen,3 Tim L Jansen,3
Tuhina Neogi,4 H Ralph Schumacher,1 Nicola Dalbeth5
ABSTRACT
Background Although there has been major progress
in gout imaging, no gout classification criteria currently
include advanced imaging techniques.
Objective To examine the usefulness of imaging
modalities in the classification of gout when compared
to monosodium urate (MSU) crystal confirmation as the
gold standard, in order to inform development of new
gout classification criteria.
Methods We systematically reviewed the published
literature concerning the diagnostic performance of plain
film radiography, MRI, ultrasound (US), conventional CT
and dual energy CT (DECT). Only studies with MSU
crystal confirmation as the gold standard were included.
When more than one study examined the same imaging
feature, the data were pooled and summary test
characteristics were calculated.
Results 11 studies (9 manuscripts and 2 meeting
abstracts) satisfied the inclusion criteria. All were set in
secondary care, with mean gout disease duration of at
least 7 years. Three features were examined in more
than one study: the double contour sign (DCS) on US,
tophus on US, and MSU crystal deposition on DECT. The
pooled (95% CI) sensitivity and specificity of US DCS
were 0.83 (0.72 to 0.91) and 0.76 (0.68 to 0.83),
respectively; of US tophus, were 0.65 (0.34 to 0.87) and
0.80 (0.38 to 0.96), respectively; and of DECT, were
0.87 (0.79 to 0.93) and 0.84 (0.75 to 0.90),
respectively.
Conclusions US and DECT show promise for gout
classification but the few studies to date have mostly
been in patients with longstanding, established disease.
The contribution of imaging over clinical features for
gout classification criteria requires further examination.
INTRODUCTION
Classification criteria are necessary to ensure rela-
tive homogeneity of participants in clinical
research, including clinical trials and epidemio-
logical studies.1 The definitive classification of gout
relies on the microscopic identification of monoso-
dium urate (MSU) crystals in synovial fluid or from
tophi.2 However, examination of synovial fluid may
not be practical for all studies, such as those with
an epidemiological focus. Therefore, clinical classi-
fication criteria also exist for gout. The most
widely used clinical classification criteria are the
1977 American Rheumatology Association (ARA)
preliminary classification criteria of acute arthritis
of primary gout.3 4
The 1977 ARA clinical criteria included two
plain radiography features: asymmetric swelling
Ogdie A, et al. Ann Rheum Dis 2015;74:1868–1874. doi:10.1136/annrheumdis-2014-205431
within a joint, and subcortical cysts without ero-
sions.4 Since 1977, major advances have been made
in the imaging of gout, and new imaging modalities
have become more widely available and commonly
used in clinical practice.5 Inclusion of such imaging
tests, if they can distinguish gout from not-gout,
may be helpful in the clinical classification of gout.
However, it remains unclear how accurate and
useful available imaging modalities are for the clas-
sification of gout, particularly when compared to
the microscopic confirmation of MSU crystals as
the gold standard test.
The objective of this study was to examine the
usefulness of imaging modalities in the classifica-
tion of symptomatic gout when compared to MSU
crystal confirmation as the gold standard. We sys-
tematically reviewed the published literature con-
cerning the diagnostic performance of plain film
radiography (x-ray), MRI, ultrasound (US), conven-
tional CT and dual energy CT (DECT). This sys-
tematic review was performed to inform the
development of new classification criteria for gout.2
METHODS
Literature search
A systematic search was performed by a medical
librarian using Ovid Medline, PubMed, Embase
and Cochrane databases from January 1946 to
March 2014. Search terms included gout, podagra,
crystal arthrop$, toph$, imaging, arthrography,
radiography, ultrasound, radiograph, plain x-ray,
MRI, tomography, CT, dual energy CT and DECT.
(Complete search strategy listed in online supple-
mentary file 1.) Articles were excluded from the
search if they were not published in the English
language, did not involve human subjects or were
case reports (as these reports did not include com-
parator patients and thus would not meet the inclu-
sion criteria as described below). We also searched
the American College of Rheumatology (ACR) and
European League Against Rheumatism (EULAR)
meetings for relevant abstracts from 2007 to 2013.
All abstracts with ‘gout‘ in the title or body were
reviewed.
Review of literature
After the initial searches were completed, AO
reviewed all the resulting titles and abstracts.
Citations were excluded if the title or abstract was
not relevant to the goals of the review. Full manu-
scripts of the remaining citations were reviewed by
AO. Review articles were excluded but references
within review articles were searched to ensure
 Downloaded from http://ard.bmj.com/ on October 8, 2017 - Published by group.bmj.com
adequate capture of all relevant articles. When not enough
information was provided in the abstract or manuscript, authors
were emailed to obtain further data.
Selection criteria
Inclusion criteria were: (a) studies examining the diagnostic per-
formance of an imaging modality (X-ray, MRI, US, CT or
DECT) in gout; (b) inclusion of at least two groups of patients
where one group had gout; and (c) gout was confirmed by the
presence of MSU crystals in joint fluid. The article or abstract
also had to include either the raw results ( positive vs negative
imaging features for each group), or specificity and sensitivity.
Exclusion criteria were: (a) use of clinical criteria or physician-
or patient-report for classification of gout instead of MSU
crystal confirmation; (b) lack of a control or comparison group;
(c) cases with asymptomatic hyperuricaemia; or (d) insufficient
information provided to calculate sensitivity and specificity.
Data extraction and quality assessment
Data were extracted from manuscripts by AO and ND using a
standardised data abstraction tool. The Quality Assessment of
Diagnostic Accuracy Studies (QUADAS) tool was then applied
by AO and ND. When there were differences in QUADAS
scores between AO and ND, WT served as a third reviewer to
settle discrepancies. The QUADAS is a 14-item scale designed to
assess the quality of studies of diagnostic accuracy included in
systematic reviews.6
Meta-analysis
When more than one study examined the same imaging feature,
the data were pooled and summary test characteristics were cal-
culated from the hierarchical summary receiver operating char-
acteristic (HSROC) curve model of Rutter and Gatsonis
implemented in R software V.0.5.5.7 8 Summary ROC curves
were then generated. In generating the HSROC, we did not
assume similar thresholds across studies since a ‘positive’ test
depended on observer judgment rather than objective
measurement.
Figure 1 Search results. Ovid
Medline, PubMed, Embase and
Cochrane databases were searched
using the search strategy in the online
supplementary file 1. In addition,
proceedings from the American College
of Rheumatology (ACR) and European
Union League Against Rheumatism
(EULAR) annual meetings from
2007–2012 were searched for relevant
abstracts.
Ogdie A, et al. Ann Rheum Dis 2015;74:1868–1874. doi:10.1136/annrheumdis-2014-205431
Clinical and epidemiological research
Results were compiled using Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) and Standards
for Reporting of Diagnostic Accuracy (STARD) guidelines.9 10
RESULTS
Study identification
A total of 1171 manuscripts and 88 abstracts were reviewed
(figure 1). Among manuscripts identified, 884 were excluded
after review of the title and abstract, 338 were excluded after
review of the paper, and one duplicate was excluded. Among
ACR and EULAR meeting abstracts identified, 88 were excluded
after review and additional information was sought in three. Of
these, only one response was received; this abstract was
excluded as the classification of gout cases was based on 1977
ARA clinical criteria rather than MSU crystal confirmation. A
total of 11 studies were included in the analysis: nine full length
manuscripts11–19 and two meeting abstracts.20 21 Seven studies
examined US, three studies examined DECT and one examined
X-ray features of the sternomanubrial joint.
Quality assessment
Overall, the included studies met most of the quality indicators
of the QUADAS tool (figure 2 and online supplementary table
S1). The most common quality issues were unreported time
between arthrocentesis confirming MSU crystals (reference test),
and the performance of the imaging (index) test and lack of
reporting of withdrawals or uninterpretable results.
Patient and study characteristics
Study characteristics are shown in table 1. Most studies were
single centre (with exception of Naredo et al14) case–control or
cross-sectional studies comparing gout to other types of arth-
ritis. Patients were generally referred to the study with joint
swelling and were recruited from secondary care clinics. In the
four studies that reported disease duration, the mean duration
of gout ranged from 7 to 13 years. However, half of the patients
in one study (Bongartz et al19) had symptom duration of
<6 weeks. In most studies, both active joints and inactive joints
were included in the analysis. Arthrocentesis was performed in
all patients with gout, although it was often not clear when the
1869
 Downloaded from http://ard.bmj.com/ on October 8, 2017 - Published by group.bmj.com
Clinical and epidemiological research
Figure 2 Methodologic quality as
assessed using the QUADAS tool. The
vertical access contains the individual
quality metrics and the horizontal
access reflects the proportion of
studies meeting these criteria (in
green). Yellow signifies that it was
unclear whether the study met the
quality metric (usually because it was
reported) and red signifies that the
study specifically did not meet that
metric.
arthrocentesis occurred relative to the imaging test. Only half of
the studies reported performing arthrocentesis in the control/
comparator patients.
Imaging features
A variety of imaging features were examined in the studies
included (table 2). There was also substantial variation in the
joints examined in each study (table 2). In the studies examining
US, most of the sonographers were rheumatologists with train-
ing in musculoskeletal US (5/7 studies; two studies did not
report the sonographer’s training). Four of seven US studies uti-
lised sonographers blinded to the patient’s diagnosis, one study
had one blinded and one unblinded sonographer, and two
studies did not report whether the sonographer was blinded. In
all three DECT studies, the images were interpreted by musculo-
skeletal radiologists who were blinded to the diagnosis.
Pooled results
Only three imaging features were examined in more than one
study: the double contour sign (DCS) on US, presence of tophus
on US, and MSU crystal deposition on DECT. Pooled results are
presented in table 3. The pooled (95% CI) sensitivity and speci-
ficity of DCS were 0.83 (0.72 to 0.91) and 0.76 (0.68 to 0.83),
respectively. The pooled (95% CI) sensitivity and specificity for
tophus on US were 0.65 (0.34 to 0.87) and 0.80 (0.38 to 0.96),
respectively. DECT had pooled (95% CI) sensitivity and specifi-
city of 0.87 (0.79 to 0.93) and 0.84 (0.75 to 0.90). The
summary ROC curves are shown in figure 3.
DISCUSSION
In this systematic review and meta-analysis, we found 11 studies
examining the accuracy of imaging features for the classification
of gout. Relatively few studies met the inclusion criteria requir-
ing MSU crystal confirmation as the gold standard and the
inclusion of a comparison group without gout. The three
imaging findings examined in the pooled analysis had similar
pooled specificity; and pooled sensitivity was high for both DCS
and DECT but lower for US identification of tophi. The results
available suggest that US and DECT may be useful to include in
revised gout clinical classification criteria.
The value of each modality for classification of gout in terms
of sensitivity and specificity in comparison to MSU crystal
proven gout as the gold standard (rather than ACR criteria or
physician diagnosis) has not previously been explored in a
1870 Ogdie A, et al. Ann Rheum Dis 2015;74:1868–1874. doi:10.1136/annrheumdis-2014-205431
meta-analysis. Three previous systematic reviews have examined
the usefulness of ultrasound as an outcome tool in gout.
Chowalloor et al22 and Ottaviani et al23 provided an extensive
review of the features of gout reported in US studies to date but
did not focus on the diagnostic or classification properties of
these features and did not perform a meta-analysis. Mathieu
et al performed a systematic literature review and meta-analysis
of the prevalence of ultrasound characteristics in gout.24
However, in examining the test properties of ultrasound, none
of these reviews specifically restricted the gold standard to dem-
onstration of MSU crystals. This is important because compari-
son of a new test to a reference standard that may or may not
be accurate can lead to inflation or deflation of the sensitivity
and specificity of the index test.
Interpretation of the results reported in this study requires
some important considerations. First, the patients studied had
been diagnosed with gout for an average of at least 7 years in
those studies reporting length of disease. These imaging modal-
ities may perform differently in patients with early gout. It is
this population of patients with earlier gout, most often without
tophi, for which an accurate imaging technique would be most
useful. Thus, further studies are needed to address this popula-
tion. It is also important to note that we excluded studies exam-
ining the use of imaging modalities in patients with
asymptomatic hyperuricaemia only, as the proposed new classifi-
cation criteria will apply to people with symptomatic disease,
rather than those with asymptomatic hyperuricaemia and/or
asymptomatic MSU crystal deposition.2 Therefore, studies
examining the use of imaging modalities to determine risk of
symptomatic gout or the presence of subclinical gout in patients
with asymptomatic hyperuricaemia were beyond the scope of
this review.
A further issue when considering imaging for gout classifica-
tion is the observation that all the studies involved patients in
secondary care rheumatology clinics. Patients recruited from sec-
ondary care setting may have more complex and severe gout
than those treated in primary care. Gout is mostly managed
within primary care, and a key property of new classification cri-
teria for gout is that they should be applicable to patients within
a range of research settings, including primary care.2 25
We used MSU crystal identification as the gold standard, but
even this test has some variability when performed by different
investigators.26 However, this is the best gold standard available.
Additionally, not all joints included in these imaging analyses
Ogdie A, et al. Ann Rheum Dis 2015;74:1868–1874. doi:10.1136/annrheumdis-2014-205431

Table 1 Patient characteristics

Gout patients Comparator patients

Disease
duration, Age, years Age, years
Study Design Population Dates N years (mean) (mean) N (mean) Arthrocentesis Conditions

Downloaded from http://ard.bmj.com/ on October 8, 2017 - Published by group.bmj.com

Ultrasound
Ottaviani et al15 Prospective Hospital outpatients with 11/2008–10/2010 53 9.2 59.7 50 59.5 Yes CPPD, RA, OA, PsA
case–control rheumatic disease
Lamers-Karnebeek Prospective Patients presenting with mono- NR 26 NR 63.5 28 NR Yes CPPD, ReA, PsA, OA, PMR, UA, Lofgren
et al18 cross-sectional or oligoarthritis syndrome, gout with neg MSU
(2 patients)
Thiele et al17 Retrospective Rheumatology clinic patients 11/2003–12/2004 23 NR 58.6 23 NR No CPPD, RA, sarcoidosis, OA, FMS, PsA,
case–control with unclear diagnosis bursitis, tendinitis, inflammatory
oligoarthritis NOS, lateral epicondylitis,
muscle fibre tear
Naredo et al14 Prospective Rheumatology and general NR 91 7 56.4 42 56.6 NR RA, SpA, healthy
case–control practice clinics
Nalbant et al13 Prospective Patients with subcutaneous 5/2001–10/2001 10 10.7 61.3 13 56.5 NR RA
case–control nodules and rheumatic disease
attending rheumatology clinics
Ponce et al21* Prospective Patients with joint effusion NR 13 NR NR 88 NR Yes OA, RA, SpA, UIA, CTD, CPPD, bursitis,
cross-sectional AVN, haemorrhagic joint
Bergner et al20* Cross-sectional Patients undergoing NR 39 NR NR 74 NR Yes CPPD, non-crystal arthropathy
arthrocentesis
Dual energy computed tomography
Glazebrook et al12 Retrospective Patients with arthralgia and 4/2008–2/2010 12† NR NR 19 NR Yes CPPD, possible diagnoses of RA,

Clinical and epidemiological research

cross-sectional potential gout seronegative IA, and CTS
Bongartz et al19 Prospective Patients with joint pain or 10/2010–9/2012 40 NR‡ 62.1 41 58.7 Yes OA, RA, septic arthritis, CTD, CPPD,
case–control swelling in rheumatology unknown
procedure clinic
Choi et al11 Prospective Clinic patients with arthritis 12/2009–6/2011 40 13 62 40 53 NR RA, PsA, OA, UIA, AS
case–control
Plain radiography
Parker et al16 Retrospective Patients undergoing routine 1978–1980 20 NR 60.8 Healthy: 69 Healthy: 52.6 NR Among those with arthritis: RA, ReA, AS,
cross-sectional lateral CXR Arthritis: 88 Arthritis: 58 PsA, CPPD, PMR, DISH
*Refers to an abstract.
†43 patients included in study initially but only 12 were found to have MSU crystals.
‡20 patients had symptom duration <6 weeks.
AS, ankylosing spondylitis; AVN, avascular necrosis; CPPD, calcium pyrophosphate disease; CTD, connective tissue disease; CXR, chest radiograph; DISH, diffuse idiopathic skeletal hyperostosis; NR, not reported; OA, osteoarthritis; PMR, polymyalgia
rheumatica; PsA, psoriatic arthritis; RA, rheumatoid arthritis; ReA, reactive arthritis; SpA, spondyloarthropathy; UIA, undifferentiated inflammatory arthritis.
1871
 Downloaded from http://ard.bmj.com/ on October 8, 2017 - Published by group.bmj.com

Clinical and epidemiological research

Table 2 Study characteristics

Active
joints Arthrocentesis of
Study Training Blinded Features examined Joints included only all imaged joints

Ultrasound
Ottaviani et al15 Rheumatologists Reader Double contour sign and tophus Bilateral MTP1, MTP2, knees, No No
trained in MSK US 1: no at MTP, knee, MCP MCP2, MCP3 (10 joints total)
Reader
2: yes
Lamers-Karnebeek Rheumatologists Yes Double contour sign and tophus Knee, MTP1, wrist, ankle No No
et al18 (2 trainees, 2 at MTP1, knee, wrist, ankle, MCP,
established) elbow
Thiele et al17 Rheumatologist Yes Double contour sign Humeral head, humero-radial joint, Yes No
trained in MSK US MTP effusion MCP joints, knee, MTP1
Second Power Doppler of synovium
rheumatologist with
limited training
Naredo et al14 Rheumatologists Yes Double contour sign Bilateral elbow, radiocarpal, midcarpal, No No
trained in MSK US intra-articular, intra-bursal, or tendon/ ulnar-carpal, first through fifth MCP,
ligament hyperechoic aggregates or knee, tibiotalar, talonavicular, and first
hyperechoic linear band MTP, wrist extensor and flexor
tendons, quadriceps tendon, patellar
tendon, ankle retromalleolar medial
and lateral tendons, ankle extensor
tendons, Achilles tendon, and medial
and lateral collateral ligaments of the
knee, deep infrapatellar bursa,
retrocalcaneal bursa and
gastrocnemius, semimembranosus
bursae
Nalbant et al13 Rheumatologist NR Nodule characteristics: density Sites of nodule involvement Yes No
trained in MSK US (homogenous or heterogenous),
hypoechoic, hyperechoic, post
acoustic shadow, adjacent cortical
bone irregularity, adjacent bursitis
Ponce et al21* Not reported Yes Fluid characteristics: cloudy, anechoic, Knees, shoulders, elbows, ankles, Yes Yes
cloudy, mixed, dotted, corpuscular, MCPs, Baker cysts
granular
Bergner et al20* NR NR Double contour sign, synovitis, Knees, small finger or toe joints, Yes Yes
hypervascularisation elbows, ankles, shoulders, wrists
Dual energy computed tomography
Glazebrook et al12 2 MSK radiologists Yes MSU crystal deposition Affected joint Yes No
Bongartz et al19 2 MSK radiologists Yes MSU crystal deposition Affected joint† Yes Yes
Choi et al11 MSK radiologist Yes MSU crystal deposition All peripheral joints (elbows, wrists, No No
hands, knees, ankles and feet)
Plain radiography
Parker et al16 Rheumatologist and Yes Inflammatory bone changes Sternomanubrial joints No No
radiologist Proliferative bone changes
Joint fusion
*Refers to an abstract.
†A secondary analysis in Bongartz et al. examine all joints but this analysis was not included in the meta-analysis.
MSK, musculoskeletal, MSU, monosodium urate, US, musculoskeletal ultrasound, MCP, metacarpophalangeal joint, MTP, metatarsophalangeal joint, NR, not reported.

were sites at which arthrocentesis had been performed. We do
not believe this should substantially affect the results, particu-
larly as this mirrors current clinical practice in which a patient is
diagnosed or classified as having gout when multiple joints are
inflamed but MSU crystals are identified on arthrocentesis from
one joint. Finally, there may be a risk of misclassification bias in
that not all comparator patients underwent arthrocentesis to
confirm their ‘control’ status.
The methods employed by the included studies were, in
general, satisfactory. However, the majority of studies utilised a
case–control design. Such designs may exaggerate the diagnostic
properties (sensitivity and specificity). Future studies may con-
sider cross-sectional designs in which patients for whom the
clinical question ‘does this patient have gout?’ are referred for
1872
participation. This type of design was implemented in some of
the studies included.12 18 20 21 Finally, there was great variability
in the study protocols used and the sites that were imaged.
Standardisation of the methodology used for both ultrasound
and DECT are needed. One of the goals of Naredo et al was to
examine optimum sites for inclusion in US studies.14 At present,
it is similarly unclear which sites are optimal for DECT
imaging, and also which scanner settings are most appropriate
to achieve optimal sensitivity and specificity for urate
deposition.27
In summary, although imaging modalities such as ultrasound
and DECT show promise in the classification of symptomatic
gout, the studies to date have been small and have primarily
involved people with longstanding, established disease.
Ogdie A, et al. Ann Rheum Dis 2015;74:1868–1874. doi:10.1136/annrheumdis-2014-205431
 Downloaded from http://ard.bmj.com/ on October 8, 2017 - Published by group.bmj.com

Clinical and epidemiological research

Table 3 Meta-analysis results

Individual study parameters

True False False True

positive positive negative negative Sensitivity Specificity Sensitivity Specificity AUC

Ultrasound: double contour sign

Ottaviani et al15 NR NR NR NR 0.67 0.98 0.83 (0.72–0.91) 0.76 (0.68–0.83) 0.84
Lamers-Karnebeek et al18 20 7 6 21 0.77 0.75
Thiele et al17 34 0 3 26 0.92 1.00
Naredo et al14 68 7 23 35 0.75 0.83
Bergner et al20 36 21 3 53 0.92 0.72
Ultrasound: tophus
Ottaviani et al15 NR NR NR NR 0.74 1.00 0.65 (0.34–0.87) 0.80 (0.38–0.96) 0.75
Lamers-Karnebeek et al18 5 2 21 26 0.19 0.93
Thiele et al17 27 0 10 26 0.73 1.00
Naredo et al14 78 11 13 31 0.86 0.74
Nalbant et al13 15 3 5 17 0.75 0.85
Dual energy computed tomography: MSU crystal deposition
Glazebrook et al12 12 4 0 15 1 0.79 0.87 (0.79–0.93) 0.84 (0.75–0.90) 0.90
Bongartz et al19 36 7 4 34 0.90 0.83
Choi z et al19 34 3 6 37 0.78 0.93
AUC, area under the curve; MSU, monosodium urate, NR, not reported.

Determination of whether these imaging modalities should be the usefulness of imaging modalities in the diagnosis of symp-
included in the revised ACR/EULAR classification criteria for tomatic gout should focus on patients with recent onset joint
gout will occur at a consensus meeting adjacent to EULAR in pain and swelling, and should use MSU crystal identification as
Paris, France in June 2014. Future studies aiming to determine the gold standard when determining test characteristics.

Figure 3 Hierarchical summary receiver operator curves (HSROC). Hierarchical summary receiver operating characteristic curve for (a) ultrasound
double contour sign, (b) tophi on ultrasound, and (c) DECT. The closed points represent the individual studies in the review. The open point
represents the pooled sensitivity and specificity estimate, and the enclosed shape represents the bivariate 95% CI for the pooled sensitivity and
specificity estimate.
Ogdie A, et al. Ann Rheum Dis 2015;74:1868–1874. doi:10.1136/annrheumdis-2014-205431 1873
 Downloaded from http://ard.bmj.com/ on October 8, 2017 - Published by group.bmj.com
Clinical and epidemiological research
Additional studies are also needed to determine which imaging
modalities are optimal and to examine the relative contribution
of imaging modalities over clinical elements to the classification
of gout in clinical situations including primary care.
Correction notice This article has been corrected since it was published Online
First. In table 3, the sensitivity and specificity for Choi et al (last line in the table)
have been corrected.
Acknowledgements We thank Janet Joyce for performing the literature search
and Yihui Connie Jiang for administrative support.
Contributors All authors assisted in study conception, design and interpretation.
AO, ND and WJT reviewed the articles to be included in the review. AO and ND
extracted the data. AO, ND, WJT and MW performed the data analysis. AO wrote
the first draft of the manuscript and all of the authors reviewed and edited the
manuscript.
Funding This study was funded by the American College of Rheumatology and the
European Union League Against Rheumatism. AO is supported by NIH
K23AR063764. ND is supported by the Health Research Council of New Zealand.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement All data utilised in the study has been published within
the individual manuscripts. The database used for analysis is available upon request.
REFERENCES
1 Singh J, Solomon DH, Dougados M, et al. Classification and Response Criteria
Subcommittee of the Committee on Quality Measures, American College of
Rheumatology. Development of classification and response criteria for rheumatic
diseases. Arthritis Rheum 2006;55:348–52.
2 Dalbeth N, Fransen J, Jansen TL, et al. New classification criteria for gout: a
framework for progress. Rheumatology (Oxford) 2013;52:1748–53.
3 Malik A, Schumacher H, Dinnella J, et al. Clinical diagnostic criteria for gout:
comparison with the gold standard of synovial fluid crystal analysis. J Clin
Rheumatol 2009;15:22–4.
4 Wallace S, Robinson H, Masi A, et al. Preliminary criteria for the classification of the
acute arthritis of primary gout. Arthritis Rheum 1977;20:895–900.
5 Girish G, Glazebrook K, Jacobson J. Advanced imaging in gout. Am J Roentgenol
2013;201:515–25.
6 Whiting P, Rutjes A, Reitsma J, et al. The development of QUADAS: a tool for the
quality assessment of studies of diagnostic accuracy included in systematic reviews.
BMC Med Res Methodol 2003;25:25.
1874 Ogdie A, et al. Ann Rheum Dis 2015;74:1868–1874. doi:10.1136/annrheumdis-2014-205431
7 Philippe D. Meta-Analysis of Diagnostic Accuracy (2013). R package version 0.5.5.
2014 (Apr 30).
8 Rutter CM, Gatsonis CA. A hierarchical regression approach to meta-analysis of
diagnostic test accuracy evaluations. Stat Med 2001;20:2865–84.
9 Bossuyt P, Reitsma J, Bruns D, et al. Towards complete and accurate reporting of
studies of diagnostic accuracy: the STARD initiative. Fam Pract 2004;21:4–10.
10 Moher D, Liberati A, Tetzlaff J, PRISMA Group, et al. Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol
2009;62:1006–12.
11 Choi H, Burns L, Shojania K, et al. Dual energy CT in gout: a prospective validation
study. Ann Rheum Dis 2012;71:1466–71.
12 Glazebrook K, Guimarães L, Murthy N, et al. Identification of intraarticular and
periarticular uric acid crystals with dual-energy CT: initial evaluation. Radiology
2001;261:516–24.
13 Nalbant S, Corominas H, Hsu B, et al. Ultrasonography for assessment of
subcutaneous nodules. J Rheumatol 2003;30:1191–5.
14 Naredo E, Uson J, Jiménez-Palop M, et al. Ultrasound-detected musculoskeletal
urate crystal deposition: which joints and what findings should be assessed for
diagnosing gout? Ann Rheum Dis 2014;73:1522–8.
15 Ottaviani S, Richette P, Bardin T, et al. Ultrasonography in gout: a case-control
study. Clin Exp Rheumatol 2012;30:499–504.
16 Parker V, Malhotra C, Ho GJ, et al. Radiographic appearance of the sternomanubrial
joint in arthritis and related conditions. Radiology 1984;153:343–7.
17 Thiele R, Schlesinger N. Diagnosis of gout by ultrasound. Rheumatology (Oxford)
2007;46:1116–21.
18 Lamers-Karnebeek F, van Riel P, Jansen TL. Additive value for ultrasonographic
signal in a screening algorithm for patients presenting with acute mono-/
oligoarthritis in whom gout is suspected. Clin Rheumatol 2014;33:555–9.
19 Bongartz T, Glazebrook K, Kavros S, et al. Dual-energy computed tomography for
the diagnosis of gout: an accuracy and diagnostic yield study. Ann Rheum Dis
2015;74:1072–77.
20 Bergner R, Peters L, Schmitt V, et al. Arthrosonographic findings in crystal
arthropathies. Ann Rheum Dis 2013;72(Suppl 3):713.
21 Ponce A, Surís X, Cerdà D, et al. Echographic patters of synovial fluid: can they
predict the results of microscopic cell counts? Ann Rheum Dis 2009;68(Suppl 3):330.
22 Chowalloor P, Keen H. A systematic review of ultrasonography in gout and
asymptomatic hyperuricaemia. Ann Rheum Dis 2013;72:638–45.
23 Ottaviani S, Bardin T, Richette P. Usefulness of ultrasonography for gout. Joint Bone
Spine 2012;79:441–5.
24 Mathieu S, Pereira B, Couderc M, et al. Usefulness of ultrasonography in the
diagnosis of gout: a meta-analysis. Ann Rheum Dis 2013;72:e23.
25 Dalbeth N. Management of gout in primary care: challenges and potential
solutions. Rheumatology (Oxford) 2013;52:1549–50.
26 Berendsen D, Jansen TL, Taylor W, et al. A critical appraisal of the competence of
crystal identification by rheumatologists. Ann Rheum Dis 2013;72: Abstract 629.
27 Dalbeth N, Choi HK. Dual-energy computed tomography for gout diagnosis and
management. Curr Rheumatol Rep 2013;15:301.
 Downloaded from http://ard.bmj.com/ on October 8, 2017 - Published by group.bmj.com

Imaging modalities for the classification of

gout: systematic literature review and
meta-analysis
Alexis Ogdie, William J Taylor, Mark Weatherall, Jaap Fransen, Tim L
Jansen, Tuhina Neogi, H Ralph Schumacher and Nicola Dalbeth

Ann Rheum Dis 2015 74: 1868-1874 originally published online June 10,
2014
doi: 10.1136/annrheumdis-2014-205431

Updated information and services can be found at:

http://ard.bmj.com/content/74/10/1868

These include:

Supplementary Supplementary material can be found at:

Material http://ard.bmj.com/content/suppl/2014/06/11/annrheumdis-2014-2054
31.DC1
http://ard.bmj.com/content/suppl/2016/01/27/annrheumdis-2014-2054
31.DC2
References This article cites 25 articles, 7 of which you can access for free at:
http://ard.bmj.com/content/74/10/1868#BIBL

Email alerting Receive free email alerts when new articles cite this article. Sign up in the
service box at the top right corner of the online article.

Topic Articles on similar topics can be found in the following collections

Collections ARD Lay summaries (83)
Degenerative joint disease (4641)
Genetics (969)
Musculoskeletal syndromes (4951)
Clinical diagnostic tests (1282)
Radiology (1113)
Radiology (diagnostics) (750)

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/